June 6, 2019
The Pharmacy Prior Authorization program is designed to promote appropriate drug selection, length of therapy, and use of specific drugs while improving the overall quality of care.
Premera has added new review criteria based on clinical best practice and approval by an independent pharmacy and therapeutics committee. Drugs may be added or deleted from this list without notification.
If you have questions, read more about the Pharmacy Prior Authorization program or call the Pharmacy Services Center at 888-261-1756 or fax us at 888-260-9836, Monday through Friday, 8 a.m.-5 p.m. Pacific time.
Which new edits are included in the Pharmacy Prior Authorization Edit Program?
Effective: March 15, 2019
Qbrexza™ (glycopyrronium cloth)
Read the full policy.
Coverage criteria
Qbrexza ™ may be considered medically necessary for the treatment of primary axillary hyperhidrosis in adults and pediatric patients 9 years of age and older who have failed treatment with prescription antiperspirants.
Effective: March 15, 2019
Odomzo®(sonidegib)
Read the full policy.
Coverage criteria
Odomzo®(sonidegib) may be considered medically necessary for adult patients with ANY of the following:
- Locally advanced basal cell carcinoma (BCC) that has recurred following surgery or radiation therapy
- Locally advanced BCC in patients who aren’t candidates for surgery or radiation therapy
Effective: May 1, 2019
Aemcolo™ (rifamycin)
Read the full policy.
Coverage criteria
Aemcolo™ (rifamycin) may be considered medically necessary when medical records show Aemcolo™ will be used for the following indication:
- Treatment of Traveler’s Diarrhea (TD) in patients 18 years of age and older when the patient has tried and failed azithromycin and a fluoroquinolone antibiotic (eg., ciprofloxacin, levofloxacin) for TD or documentation is provided why azithromycin and a fluoroquinolone antibiotic aren’t clinically appropriate
- The quantity prescribed for TD is a one-time fill of Aemcolo™ 388 mg (two 194 mg tablets) taken twice daily for three days (12 tablets total).
Rocklatan™ (netarsudil and latanoprost)
Read the full policy.
Coverage criteria
Rocklatan™ (netarsudil and latanoprost) may be considered medically necessary to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension when the patient has failed trial of two ophthalmic beta-blockers (eg, timolol, betaxolol) and two ophthalmic prostaglandins (eg, latanoprost, bimatoprost).
Natpara® (parathyroid hormone)
Read the full policy.
Coverage criteria
Natpara® (parathyroid hormone) may be considered medically necessary when ALL of the following criteria have been met:
- Patient is 18 years and older and diagnosed with hypocalcemia with hypoparathyroidism within the last year
- Patient is using calcium supplements
- Patient is using an active form of vitamin D (e.g. calcitriol, cholecalciferol, ergocalciferol)
- Albumin-corrected serum calcium is at least 7.5 mg/dL
- Patients does not have acute post-surgical hypoparathyroidism
- Prescribed by or in consultation with an endocrinologist
- The quantity prescribed is limited to two cartridges per 28 days
Initial approval will be for 1-year.
Reauthorization criteria
Continued therapy will be approved for 1-year when documentation shows the albumin-corrected total serum calcium concentration is between 7.5 mg/dL and 10.6 mg/dL
Forteo® (teriparatide),
Tymlos® (abaloparatide)
Read the full policy.
Coverage criteria
Forteo® (teriparatide) or Tymlos® (abaloparatide) may be considered medically necessary for the treatment of osteoporosis when the following criteria are met:
- Patient tried and failed or had intolerance to two generic bisphosphonates (either two oral medications or one oral medication and one IV medication) unless use of bisphosphonate medications are contraindicated
- Total duration of therapy is less than or equal 24 months
Note: Generic bisphosphonates include alendronate (oral), ibandronate (oral), risedronate (oral) and zoledronic acid (IV)
Phoslyra® (calcium acetate),
Fosrenol® (lanthanum carbonate),
Renagel® (sevelamer HCl),
Renvela® (sevelamer carbonate),
Velphoro® (sucroferric oxyhydroxide)
Read the full policy.
Coverage criteria
Phoslyra® (calcium acetate), Fosrenol® (lanthanum carbonate), Renagel® (sevelamer HCl), Renvela® (sevelamer carbonate) and Velphoro® (sucroferric oxyhydroxide) may be considered medically necessary for the treatment of hyperphosphatemia when the following criteria are met:
- Patient has tried and failed or had an intolerance to sevelamer HCl or sevelamer carbonate.
Auryxia® (ferric citrate)
Read the full policy.
Coverage criteria
Auryxia® (ferric citrate) may be considered medically necessary for the treatment of hyperphosphatemia when the following criteria are met:
- Patient has tried and failed or had an intolerance to sevelamer HCl or sevelamer carbonate.
Auryxia® ferric citrate) may be considered medically necessary for the treatment of iron deficiency anemia when the following criteria are met:
- Patient has tried and failed or had an intolerance to both oral iron and IV iron.
Note: Examples of oral iron include ferrous fumarate, ferrous gluconate and ferrous sulfate. Examples of IV iron include ferric carboxymaltose (Injectafer®), ferric pyrophosphate citrate (Triferic®), ferumoxytol (Feraheme®), iron dextran (INFeD®), iron sucrose (Venofer®), sodium ferric gluconate complex (Ferrlecit®).